Implications of Ethnography Research Method in Educational and Health Studies

ORIGINAL ARTICLE Background: Studies in educational and health areas are sometimes accompanied by the adoption of a qualitative research approach. Qualitative research claims to achieve natural and first-hand data in a variety of ways. In this regard, the purpose of the present study was to explain the implications of ethnography research method in educational and health settings. Methods: An analytical-deductive method was used. However, analysis of the research experiences of the authors of the paper were proceed to reach the aim of the study. Accordingly, the reliable sources as well as the background studies of the researchers were used and analyzed. Results: The findings showed that ethnography in education can provide insights into in-depth analysis of the beliefs, values, and experiences about the academic trends. Also, ethnography in health researches can lead to improving health care processes, modifying high-risk behaviors, timely prevention, managing stress in the face of illnesses, emphasizing sensitivity of local communities, health knowledge creation and, in general, influencing the entire health programs in societies. Conclusion: Given the importance of ethnography method in obtaining firsthand and in-depth results, it is recommended to provide more awareness about the effectiveness of the method, and more attention to its implementation among the research projects both in educational and health research areas.


Introduction
Studying in the field of educational and health researches sometimes comes with choosing qualitative research approach. "Qualitative research method" studies the phenomena in its social and natural context. It aims at studying formation and flow of human intercultural interactions. 1 Considering the methodological approach in answering a research question, qualitative research is often ignored. This mostly happens in academic domains, such as medicine, because in such areas evidence-based practices have developed as a popular treatment philosophy according to the quantitative research tradition. Qualitative research provides rich information, which cannot be achieved through quantitative approaches. Ethnography, as a qualitative method, includes relative submersion into the setting, which should be studied. It is also an appropriate methodology for a wide variety of research areas in healthcare and medical settings. 2 Special features of "cultural believes" and their extensive study field require utilization of qualitative research methods such as "ethnography".
In fact, combination of ethnography and participatory observation shifts the attention center from observability and qualitative to sympathetic understanding; incisive understanding. Realization of quality can prepare a form of holistic approach to social phenomena through taking accumulative, naturalist, multipurpose, interpretive, and non-predefined approach.
Leung, 3 for instance, believes that ethnography has been introduced as a social research method dealing with natural environments and characterized by learning about a specific group's culture. Furthermore, ethnography involves experiencing the group's ways of life before providing explanations about their attitudes or behavior. This approach is based on the culture and is related to the individuals' ethnicity, nationality, gender, regional origin, occupation, and generation. In the healthcare domain, the focus of ethnography is on pathology such as cancer, HIV, heart disease, or diabetes. Ethnographies are usually carried out in a single setting and their data collection procedure mostly depends on data from the participants' observation and interviews.
In addition, in clinical setting, many variables should be analyzed using a more open-ended approach rather than by survey or deriving the archived data from the hospital and the clinic databases. 4 In this regard, the patient/nurse relationship is of great importance for the success of healthcare process. Better comprehension of the dynamics allows decision makers to proceed with more reliable and pertinent information. But how can the ethnography method achieve in identification and production of reliable knowledge? In this regard, in the current paper, features of ethnography approach and its implementation terms are determined first. Then, applications of the approach along with some samples in the fields of health and education are introduced. Moreover, components and steps of executing the approach are described. Eventually, the research approach is evaluated and its weakness and strength points are discussed.
In sum, the purpose of this study was to identify the functions of ethnography research method in educational and health studies. In this regard, three main questions were examined:  What are the basic features of ethnographic research in academic studies?  What are the implications of ethnography in educational and health studies?  How can we trust ethnographic research data?

Methods
An analytical-deductive method was used. Analysis of the documents and experiences of the authors, whose research fields were often qualitative, were used. In most of their academic research, the authors of the present study used a qualitative approach and ethnography method. They have had many ethnographic research experiences, both in Iran and Sweden.
Data were collected through sources and related documents. Then, they were analyzed through deductive analysis. Accordingly, the reliable sources as well as the related studies of the researchers were analyzed.

1) Features of ethnography research method
Although ethnography has been exclusively categorized under "anthropology", but during the recent decades, it has entered to other fields of science including "Education" and "Health". When the purpose of the research is to discover the social conditions, approaches, interpersonal connections and roles regarding the overall structure of the culture, ethnography is an active research method.
Ethnography research is usually performed based on "critical" and "interpretive" analysis. This method aims at inferring its theoretical principles of anthropology including "Naturalism" and "Deep Holism". In these two approaches, human action is evaluated in a context of entire semantic and behavioral system. According to this, individual actions are cultural tools of the major socialcultural system, to precisely understand which, they must be explored in the context of the entire system. 5 Generally, ethnography is focused on observation along with participation in social life. The researcher must only analyze the data based on the experiences of the studied people sometimes, while his/her own experience in the realm of the studied persons is welcomed. 6 The final goal of ethnography research is affirming dimensions of human social life based on the theory, so that the theory and its precise estimation in textures of real human life events are counted as the main pivot of ethnography approach. 7 Hence, ethnographic studies are a rich description of phenomena and realities of the society which is carried out through a holistic interpretive approach.

2) Ethnography in health and education studies
Ethnography can be diverse in terms of type and subject; for example, including "culture ethnography", "auto-ethnography", or even with different subjects such as "school ethnography", "university ethnography", "tribe ethnography", "city architecture ethnography", "the press ethnography", "the internet ethnography", "food ethnography", "fashion ethnography", "study ethnography", "medicine ethnography", and etc. Importance of ethnography in the fields of health and education is worth mentioning. In Iran and globally, some studies have been carried out in these two fields which are discussed in the following:

2-1) Ethnography in educational studies
Several studies including "education ethnography", 8 "ethnography meta-analysis of the Sweden education system", 9 "qualitative analysis of virtual university" 10 which is sometimes named as "school ethnography" or "university ethnography", 8 are performed in regard of the subject of this sub-section.
Education ethnography can speak about school and academic culture emphasizing on school or university educational experiences, and try to propose a deep knowledge of education system through describing and explaining the experiences. In fact, "school culture" includes values, symbols, believes, and mutual meanings of parents, teachers, students, and other staff members as a part of the bigger society. Value of the issues for the group is determined by the society members, and their thinking, feeling, and behavior manner are determined by the cultural status of the school. 11 Moreover, Peterson & Deal 12 regard the "school culture" as an implicit current of norms, values, beliefs, traditions, and formalities which form as time goes by and is caused by interaction of people and encountering educational challenges in the school. A set of untold and unwritten expectations and values form the thought, feeling, and action manners in the school. In fact, "school culture" has close relation with "teaching-learning culture". The most essential phenomenon in school culture is the teaching-learning culture. 10 Teaching is a cultural activity; and cultural activities are expressed in form of culture scenarios. These scenarios are general knowledge about events that exist in minds of their creators. The scenarios guide social and individual behaviors and inform everyone about the expectations they can have from the learning and teaching processes.
On the other hand, ethnography is also applicable in analyzing the "university culture". Through semantically and interpretive definition of Geertz 13 about culture, the "academic culture" can be considered as "pattern of hidden meanings in symbolic figures including: actions, talks, and all meaningful subjects through which academic people interconnect and share their mutual experiments". Moreover, Burton Clark 14 believes there are mutual values in all university majors that represent the culture of the academic disciplines.
These mutual values guarantee and support realization of an ideal academic person. Some of these values include trying to understand more, spread the knowledge, solving explicit thought problems, having strong sense of curiosity, enthusiasm to ask, dare to give new ideas and questions, scientific honesty, being prepared to hear critics and words of the others, and meeting general human values and morals. The mentioned values are transferred to the students throughout the educational degrees. This process is known as "academic sociability" which can be expressed and analyzed in ethnographic studies.

2-2) Ethnography in health studies
Implementation of qualitative research methods including ethnography in health areas has helped the researches significantly determine the deeper problems associated with the society. In this regard, the universities have also taken measurements in expanding and exploiting these methods. The University of Leicester, 15 UK, for example, represents the "Ethnography for Healthcare Improvement" course for health education students. In this course, the following subjects and discussions are taught to the students:  Critical analysis of ethnography applications in improvement of healthcare and its different methods and measurements;  Ethnography in the Healthcare major, as well as ethnography of Healthcare activities/ management of tensions in fixing the diseases and their evaluation;  Cross-cultural variety, adaptive studies of Healthcare using ethnography methodssensitivity against local contexts of societies, time, location, and cultural complexities;  Designing and executing ethnography researches for Healthcare improvement-importance of flexibility and moral behavior inside and outside of Healthcare field;  Publication of ethnography research and its effects on policy makings and practical measurements. Luciani et al., 16 claim in their work: "overview of qualitative researches in regarding health" that the clinic staff, especially the nursing researchers, play important role in providing research data based on "field evidences", so that these researches can lead to providing awareness and improvement for health, education, and policy makings. In their idea, qualitative researches regarding health, mostly concentrate on "health-illness" continuity expression and discovery, and issues relating healthcare and its policy-makings. They take principles as essential for optimum execution of qualitative researches, including: defining a purposeful sample, determining suitable data collection approaches, having a theoretical analytic approach about the collected data, and eventually, the credible results. In general, they believe that qualitative studies can be an important part of social, organizational, team or individual evaluations in the field of health; evaluations that can obstruct or magnify the success in execution of a health program. Moreover, the results of qualitative studies about health can be string basis for creation of practical evaluation tools based on the context. Hodgson & Luig 17 presented basic steps in execution of ethnography in medicine education researches that must be carried out through the following steps:  Develop awareness about differences of the qualitative and quantitative methods;  Creation of connection with the context and the research field before beginning of the work;  Sharing the goals with the beneficiaries;  Practicing the flexibility by the researcher;  Leveling the research questions with execution method;  Preparation of the work fields;  Using diverse data collection methods;  Considering all levels of minor, median, and major levels of the research field;  Utilizing triangulation for data reliability;  Deep research description in the final report.
In addition, applications of ethnography method in health studies are obvious. For example, Lander & Balka 18 demonstrated in "evidence application manner in the field of Healthcare through organizational ethnography of two training hospitals" that Healthcare authorities of these two hospitals usually share their research experiments through web and smart phones and their experimental and professional evidences becomes mutual and sturdy gradually. They believe that using ethnography method in the field of medicine based on evidences can be helpful in daily Healthcare. Result of this kind of research shows positive impact of clinical instructions with medical measures based on these evidences.
Moreover, the study of Ledema et al., 19 "ethnography based on video data-a reflection in health studies and healthcare improvement" shows that using video data in ethnography studies in the field of health can be a strategic tool in collecting real data. This method is very popular among health researchers. The authors claim that this research tool has been popular in different medical fields including ethnography, practical and visual anthropology, medical sociology, healthcare studies, nursing and medical education, and adult education. Moreover, application of ethnography in the field of health has also been common in Iran somewhat; "Medical ethnography" and "Minor medical ethnography" for example. In this method, medical believes of people in different regions, especially ones needing more help with health norms are analyzed. Through recognizing these beliefs, their truth or falsehood are determined and procedures of health improvement of the local people get boosted as people participate more and their false medical habits change. In this regard is the research of Kor, Joybari & Sanagoo 20 which was carried out in "Minor medical ethnography" in which medical beliefs of the Turkmen people in Golestan province is discussed. This research suggests that some beliefs of the Turkmen people about women health are positive while the others are negative. In this research, detection of these behaviors and trying to boost the medical behaviors and beliefs and cultivation for removing the harmful behaviors are advised in combination of the folklore medicine with therapy and health system flowing in the country in order to improve people health.
Shafati & Zahedi 21 also discussed the ethnographic study of the doctor-patient relation in "physician-patient relationship: ecology of group examination of the patients in private clinics". The results show that very few cases of physicianpatient interactions in the studied clinics were examples of the participatory behaviors. This case was much less frequent in clinics in which visiting was carried out in groups for patients. Recognition of biological, social, and cultural aspects of the disease can affect the relationship method between the physician and the patient, better understanding of the problems and spiritual and physical problems, and even help the physician with reaching the right diagnosis and choosing and presenting the right efficient therapy option. Moreover, Zeighamy et al. 22 emphasized on importance of "auto-ethnography" in the scope of nursing. Auto-ethnography is a branch of ethnography in which the researcher explains his/her own experiments regarding the patients and nursing and benefits individual experience as a data source. Ethnography is of the newest qualitative method which has been utilized in nursing gradually. This method is essential in the sense that can play significant role in generation of new nursing knowledge.

3) Components and execution of ethnography method
The focus point of ethnography is "observation" and "listening" to people, so that they act based on their concepts. 23 This strategy has components which:  Emphasize on first-hand experiences;  Focus on data that happen naturally;  Use different methods including record of observations, different interviews, or visual data;  Utilize the "neutrality" principle of the researcher that is based on judgment about the observations.
Execution of ethnography requires some steps, including:  The ethnographer shows interest in many aspects of a social situation. He/She observes, asks questions, converses, writes notes, and spends time with ones related to the study subject; 24  The main feature of executing ethnography is "doing the research within the field". This method enables the researcher to get close to the real studied world and detect an integral set of theoretical concepts that not only create and interpret them, but also determine the relationship among them from the experience-based data; 25  Sometimes, the ethnographer becomes a "stranger actor" and must face people who observe his/her behaviors alone. Therefore, the most important point in the participatory observation method is for the ethnographer to keep silent, make his/her behavior similar to others, and make others forget his/her difference with them. Meanwhile, he/she should start conversing with them through learning their language; 26  "Writing" is the complementary part of the research for the ethnographer. He/she keeps writing along the research, and not after it. The work ends with provision of a lengthy full report about the given situation. 27

4) Credit of data from ethnography research
In ethnography research method, different ways are utilized to evaluate the research data. For example, the time when the people of the study group determine the degree up to which the research report complies with their real life narration. Linkoln & Goba 28 suggest approaches to evaluate the data of the qualitative research including ethnography, as follows:  Long-term presence of the researcher in the research field and continuous observation through multi-dimensioning the method;  Conversing with the colleagues and individuals not involved in the mentioned research to determine the blind spots of the project and discuss them;  Analyzing negative points in analytic induction, suitability of judgment basis of the interpretations and their evaluation, controlling by the members and evaluation in data connection method and interpretation by the members of the study field. The acceptability is to be determining by utilizing the "triangulation" method. This method is carried out in different aspects including triangulation of the data, researcher, theory, and methodology. In data triangulation, the studied phenomenon is analyzed in different times and locations and with different people. In the researcher triangulation, several observer or interviewer participate in data collection to minimize individual biases. In the theory triangulation, the data are analyzed from multiple theoretical dimensions. In the methodology triangulation, different mini-scales are used to determine a subject and semi-structured interview and observation tools are combined with each other in order to reach more real data. 28

Discussion
The ethnography research comes with strength and weakness points. In expressing the strength points, it should be noted that rich and holistic cultural knowledge is obtainable from the ethnography research results. 26 Moreover, "direct observation" of the research field and finding "first-hand information" in natural environment are other strengths. Data in ethnography research is based on direct observation of the culture of the people, so that its results lead to precise and direct understanding of the actors. 29 "Holistic expression presentation" of the realities is another strength point. In the ethnography research strategy, the studied events are in the main focus of the analyzed research field instead of abstraction, and reveal the hidden layers present in actions.
On the other hand, the ethnography research suffers from some weaknesses. For example, the mere description of the actions of the studied people weakens drawing of the social system structure of the people. Although, to solve this problem, some critical and analytical dimensions can be utilized along with descriptions of actions to give more depth to visage of the social system of the study. Moreover, stability of the data is not ensured in some cases. Therefore, this method can't generalize the findings except for the study group. In the meantime, Hammersley & Atkinson 30 defend the "accurate realism" and consider it as a suitable alternative for credit and stability. Hence, in the ethnography research, claiming that the data can represent a bigger society is not feasible.

Conclusion
Based on the mentioned findings, it can be concluded that ethnography method is a kind of accurate study method in procedure of studying cultural, educational, or even health believes of the societies. 31 Implementing the ethnography strategy in analyzing people beliefs is a complicated subject needing conversance of the researcher. In this regard, it should be considered that terms like preserving the normal environment of the research field, minding privacy of people, letting go of individual orientations by the researcher, and obtaining high credibility for the findings, are all difficult terms meeting of which requires high conversance of the researcher. Therefore, it can be definitely claimed that the ethnography researcher should observe the execution, interpretation, and expression of the findings terms carefully and be aware that lack of the mentioned terms can jeopardize the credit of the research findings.
The results determined that educational ethnography can clarify about procedures of school or university through deeply analyzing the beliefs, values, and academic and school educational experiments. 32 Moreover, ethnography in the field of health can reach findings such as healthcare improvement, correction of dangerous behaviors, on-time precautions, tension management when encountering the diseases, emphasize on the local sensitivities of societies, knowledge generation regarding health, and in general, impacting on health policy-makings in the society.
Considering the importance of ethnography method in reaching deep first-hand results about the unknown subjects of the health and educational challenges, this study recommends some points as setting up more awareness-giving about the effectiveness of the ethnography method, and more attention to its implementation among the research projects both in educational and health research areas.

Conflicts of Interest
In this study, was not reported any potential conflicts of interest by the authors.